818061 Clinical Services Nurse Inpatient La Palma CA

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Clinical Services Nurse – Utilization Management La Palma (818061)

Position Description

AppleCare Medical Group was formed in Lynwood, California in 1996 with the goal of making quality care available locally to the community. Today, AppleCare Medical Group is comprised of hundreds of board-certified private-practice, independent physicians. These physicians provide medical expertise and passion to improving the health of communities in the Southeast area of Los Angeles and Northern Orange County.

Responsible for the facilitation of the inpatient Utilization Management process including in-network, out of network, case management and discharge planning as well as assisting the Associate Director of Inpatient Management with UM/QM functions as necessary.  Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility.  


Primary Responsibilities:

  • Directly performs concurrent review

  • Accurately identifies and documents level of care

  • Coordinates, facilitates and documents comprehensive discharge planning

    • Coordinates in-network services for OON discharges

  • Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk

  • Attends inpatient review rounds and presents cases to medical director(s), health plans and ACMM management staff

  • Facilitates OON transfers to In-Network facilities

  • Works collaboratively with internal and hospital contract staff

    • Initiates letter of agreement for OON services in a timely manner

    • Provides input for potential contracts

    • Identifies and communicates high dollar / high risk cases

    • Oversees the utilization of contracted facilities and reports OON utilization

  • Develops and maintains relationships with both network and Out of Network hospital UM and ER staff

  • Works directly with AppleCare Hospitalists to develop and implements inpatient processes including, but not limited to:

    • Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic

    • Facilitates and ensures timely communication between PCP and Hospitalists

  •  Provides direct Case Management activities if necessary

    • Identifies readmit for CM coordinations

    • Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals

    • Identifies and coordinates high dollar/high risk patients to case management

  • Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned

  • Participates in inpatient UM/QM projects and completes in a thorough and timely manner

  • Other duties as assigned which may include weeknight, weekend, and holiday on-call

Required Qualifications:

  • Associates degree in Health Care related field
  • Active California LVN or RN license
  • Valid California Drivers license and insurance
  • Minimum of 5 years experience or above in a Managed Care environment, preferably in an IPA or MSO
  • Thorough clinical knowledge of common inpatient diagnoses
  • Understanding of DRG
  • Strong organizational skills
  • Ability to perform complex problem soling
  • Ability to work effectively with physicians
  • Knowledge of HMO, MSO, and ACO structures and operations
  • Strong people skills
  • Strong Microsoft office Word, Excel and internet skills
  • Knowledge of standardized CMS, Medicare Advantage, HMO, and Medi-Cal benefits structures

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical
practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

  • Requisition Number818061
  • Job TitleClinical Services Nurse – Utilization Management La Palma
  • Job FamilyNursing
  • Business SegmentOptumCare

Job Location Information

    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusNon-exempt